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0185 GREAT MARSH ROAD
"Ohovs, 4k ra 6 0 q - e u r rt- - Town of Barnstable Building Department Brian Florence, CBO Building Commissioner MUST COMPLY WITH HOME OCCUPATI( 200 Main Street, Hyannis, MA 026tULES AND REGULATIONS. FAILURE TO www.town.barnstable.ma.us COMPLY MAY RESULT IN FINE". Pre-application for Business Certificate Date MapA k) Parcel Applicant Information Applicants Name (7—QQ'�e' Applicants Address �a0I (�I � QUO.Email Address _ Cip ok �� and Sri PP,PeS j(, n V Telephone Number`'f_� l�( q Listed ❑ Unlisted ❑ �mUi I G Business Information New Business?CzQ� � - -- �11 Ql�_ C._ L' es No Business is a registered corporation? _______________________ . Yes If yes Name of Corporation (x+J Does business operate under the registered corporate name? Yes No Is the business a sole proprietorship or home occupation? ________ Yes No If yes then a Home Occupation Registration is required-See Building Division Staff Name of Business Q �j k?L-QI y' Business Address (101 Type of Business A wilding Commissioner fice e n Conditio r6 . Building Commissio Date? bI 1 & Clerk Office Use Only Town of.Barnstable Building Department �oFtHE r°ky Brian Florence,CBO Building Commissioner' anxNsras , « 200 Main Street,Hyannis,MA 02601 Mass. 9c� i639, ��� www.town.barnstable.ma.us PIED MP'�� Office: 508-862-403 8 Fax: 508-79.0-6230 . Approved: _ Fee: Permit#: HOME OCCUPATION RAGISTRATI0N Date:4a/g ` Name: 1 -'n�10 e#: T Y' Phon c Address: I /�9' �P�a Village: *,. Name of Business: ��o Y �. n[11 S (A P ei Type of Business: �ili'1 O Spa y Map/Lot: . 1� INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation visions of Section 4-1 A of the Zoning ordinance,provided that the within single family dwellings,subject to the pro 4 activity shall not be discernible from outside the dwelling: there shall�be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes;and no increase in air or groundwater pollution. r After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit.Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust oT other particular .matter,odors,electrical disturbance,heat,glare,humidity or other objectionable effects, • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in'excess of normal household quantities. • g generated by such use shall be met on the same lot containing the Customary Home Any need for parkin Occupation,and not within the required front yard. • There is no exterior storage of display of materials or equipment. • There are no commercial vehicles related to the Customary Home Occupation,other than one van or one pick-up truck not to exceed one ton capacity, and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. •' tised as a business,the street address shall not be If the Customary Home Occupation is listed or adver included • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit. _ e above restrictions for my home occupation I am registering. I,the undersigned,have read and agree with th Date: Applicant: Homeoc.doc Rev.10/17 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Q/U Parcel Permit# (0 Health Division Date Issued Conservation Division Fee Tax Collector Treasurer X-PRESS PERMIT Planning Dept. i MAY 2g01 Date Definitive Plan Approved by Planning Board Kim J OWN 0F BARNSTABLE Historic-OKH Preservation/Hyannis Project Street Address � S��[� a ri Village C M Ie V_ // Owner p �'�f?�^✓� - Address Telephone D V--7 7S- ©0 &,(4 Permit Request e.D� /oZ wjlnd&61 t_M,-SJJ �raa:� SdA� rcZA -aes&!2� Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Valuation Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family 0 Multi-Family(#units) Age of Existing Structure 5 ) Historic House: ❑Yes No On Old King's Highway: ❑Yes �WNo Basement Type: Full ❑Crawl 0 Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing - new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil 0 Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: 0 Yes ❑No Detached garage:0 existing ❑new size Pool:0 existing O new size Barn:0 existing 0 new size Attached garage:0 existing ❑new size Shed:O existing O new size Other: Zoning Board of Appeals Authorization O Appeal# Recorded❑ Commercial 0 Yes ❑No If yes,site plan review# Current Use Q�A-Lc C!14 Proposed Use / BUILDER INFORMATION Name 1"2A m.. M l- C[C Zr✓( Telephone Number SO ir ? 7r o e->69 Address r License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO PW!!a SIGNATURE (��.{ /r �{.�.�� DATE a d / : ,,,�, a own oBarnstable MAMRegulatory Services Thomas F. Geiler,Director Building Division Elbert Ulshoeffer, Building Commissioner 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date AFF DAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair.modernization,conversion, improvement,removal,demolition,or construction of an additiori to any preexisting owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: ?"-0,vur� Estimated Cost be)ao Address of Work:_ I k6 Owner's Name: 1, a M1'' kCWf(, Date of Application: A J I hereby certify that: Registration is not required for the following reason(s): []Work excluded by law []Job Under$1,000 Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. Date Owner's Name q:forms:Affidav L_ T7- The Commonwealth of Massacnuserrs Department of Indusrrial Accidents ollfctaltassstl�atlods . .,�� 600 Washington Street �^ Boston,Mass. 02111 Wori{ers' Comneasation insurance davit z II name �� I�) Z►�lG ���.P��/V IOC22Soit' O r• � r��i �, ' city rn T 2 rhane I am a homcaw=perfmmiag all wmc=gseif I am a sole aroorietor and have no tine worldnz in anv moidty :I am as empiover providing worioers' cnmaeasatiaa for my employees waidng on this job. : {.}}:r;,,,;!ax?...., , .:.}:.�.a>n„:. w :.::....:::::..::.:.:::.,rrw•:..rx.::•:.:.::...::.::::.,,...:.:.::..:..,.......,,,.::.:.::::::, ::::,,,,,>.,;.;: .w. ,..}r::;•}}:�:::•:::..:a:•x•:fir::::-::•}:;•::;::>}:•>:-:::;•}}:c:�:;:::�.-:::. •.:::--.�,...;...... •• .:..v.w�a•::::::.{:.:::..;..... .-.....- .............. ..... .vv+'v::;} .....•::::>}:}h}+}''C':!':i�ix}':i:o:= 'vr:•iivr}.:v::v �?}::4 4}ii}:-}Jii:.. ..:::}x.:............vv,.,.,..v .. kww\. xCEOI�wW.,: :.,.:. ! .aa............. .. :::::..:�:::::: :::::..,..:.,.::.:............... ::.::•:::••::.......... ....- ......•,M,,,,,:::�:.::::•::::•r:.:v:x^^�.�..,:•#.vim:..:..:••.. •x.,.,,....,........:-. r.f.N::::::.::::.::::.:.:..::.....,:.....:.:......................... . ::::..,.;,y.}:::::::wnv::::.y:::::::::r.:v:.�:..... ........ .....-}:.,:...::{:�:......:.�'+• w ,J!G�+"+"r{{•x:}v¢y w„♦.. {L}:v.•:}:•.vi4::•.v:-..........................::..::.•.v:.::v.:..:+-.�:::::�::v::::::::.:�:--.:.,.:.. „v::v:.....r........ ...... !MYw?.................:...::::•.v:::v:wvv:.::v.:v,::....:..r......................v::•:.�:::::.�::�.: f:J:}:i:::iR:ii:?vT}`{:�i�:ti i.'}ii:•i?}ry:.' i':YJC...:•}A}:{i;ifi} }'•ii� -::::.•:::....:::.v:...........:v::w:.....:::..........:................:.n:fi..\•+•::v.?...{•.. .... ..h... ... :•:.:..... :....:y..:v.............Y.m;?:.�:.v:::v.�:::::•.v:::::v:vvw.v..:._.::v:::•:n�n}u};!.;.;;:,;.�.. ..:...........:.............. ....,v.:nMv.}}:{' 'rM++:+::!nGx•:Jh. 7!a.. n... .: .::.•;•••w:.{.:�.J;wvxv:•.w:::•.i:ri:::v:: ...y.......,....ti.:r.... . ..}.Y.••ti iiiib}.:. ..}. {p ��}�•57 {vRy ..;i/L4:;}:isii}^..?.�:.::v`:{..:v:rP}}:i?:i}::::?:::ii!�iii i::>iv�ii:{:.}:.y: • rwv?:.v.�::.v}?:::•.�:.y........�'K•:C.}:?^:•F.:...i��fi?AMIA„nti;{.:.y::.+v�r:.YMi1�}a-.-..�.,h+]C•Y.irwi+.:•xJ6}�:.r,b.�:i;:{;i{;}}:::J:�wX .a,:,:{; .v:: .w. .. 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Pathae to seems ew.era;e as tsota3ed tender Seetlaai 2SA of MGL L4 emlrad b the iampoattia�of e�al penalties or a t3aa ap�si_�o-oo a= aoe years't=q===mt w wea AS Cha pmaltirs to the form of a STOP WORK ORDER and a fts of SIOU.t70 a day against me. I tmdzrs=d th e:tpy of this antammt maybe forwarded to tba oMcc of IarestlSsdm of the DIA for coverage rerlaadon. I do har3y certify undo the pmhr sad p=altia of pm*ry 1haiMc irrfornration provided abow u=,W.oard come&. Sigasttae f f Date _ S ofnc al use only do not write in this area to be completed by city or town omdal dty or town: peratdtlllcense tt ❑ft di Deparaazz' ❑Ilcrsssm;Board cbec3clf Ss=nedL rw"m is Mtured ❑Sdec=en's OlnCe _ ❑Health Depar=ml contact person: phone tt•, r Other_ Information and. Instrucrions 4 Mssac:7us s G=ral Laws chaster 152 section ZS mtpires all lovers to provide workers' comg===fe: eanioye:s. As quoted fit m,the "law", an ernplvvee is deimcd as ez=v person in the sertzce of another tmriz:an:;; of nirr, --: prrss or innplied, oral or written. An emnlover is deaned as an nu iyidual, partaership association, rorporanon or other,le_al entm; or say two or thr foregoing eased is a joist ezBerprise, and mcivaiag the Iegai rr-P=F MTs of a deed employer, or thz:-_: nzu-z`� of an individual,partarrsutp, association or other Iesaal emity, "emafo_ a a. . aR•elling Iznuse having not more than ilzz� �ezaalo��. Howeter th..aRzr. �. aparan=and who r=des th.-, or�occupant of the dyming 'another who ernnlovs persons to do , 64AMSMICLECALL or repair work oa such dwelling house or on tlr- r building appurteaanr thereto shah nat because of such employmrat be demcd to be an®foyer. MGL chapter 152 sCc:t=25 also-sffirs that Every state or local licensing agency shall withhold the issuance or re of a license or permit to operate a busiaass or to consfract buRdings in the cemmonwealth for any applicsnr wn not produced acceptable evidence of coonweafthmPrmnce with the izmw=ce coverage required. Additiaaally,n- thz nag say ofiLr political subdivisions sh Il eater into,say cat =farthr periormaa"cfpublic Rvrb a:, �ptable evid==of cozmlim=wig the iasuraacx ofthis chapter have been prr =cd to the �pph.nnts . � .-MCI min thhoo}wpar��}}{. c®�-1 afdav° r1R by 2 :boos that 2.�♦yam a y td ."'TJ company J e!�anLL 11G1 W oIIemmbes al®gwitlt a . to the Dcpate i of as all adavits may be Accd�for of'�r. affidavit. The --� Also be smz to siga'an; vh�Id ba Ito the shy or agplicZdm forthe pranit orlic=se is -�=g ietuested,not the Dgmz== Sbonirl ym c z i? to obtain a warmers' • •P y,Pie the D have Baas regarding the "Iaw"or if. q====the m=b=listed below. ty or Towns be sure that the arndavit is cep hasp a spat.-zt th,-bc=of far you to fiII nut mthe ev the Office of has to coffiact you regarding the agplic Tt P7=,.. to BE in the p M�mbrr-which wMbe used as a - �-'"'���� The a�davitr may be Ric D_xx==by mail or FAX unless cd=MT2Mze= have bramade. . 0fH= of oas would M=to thank you in advan=:ffir yoU CCPpCTM=sad should you have any ou.==. se do not h.- to give us a CWL . nnar=,te;,.ahaa..sad fax nBmncr: The Commonwealth-Of Massachusetts '•; _ Department of Industrial Accidents Me of IMSUoatlons 600 Washington street Boston,Ma. o2111 fax it: (617).727-7749 The Town of Barnstable t659. Regulatory Services Thomas F. Geller, Director Building Division- Elbert Ulshoeffer, Building Commissioner 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790-62:0 HOMEOWNER LICENSE EXEbiMTON Please Print DATE JOB LOCATION: �rS G Ve-7 f- j�?v`c 7 G Cie- ✓U ler,'t I nugmbers street village ..HOMEOWNER": lam✓� �l( am 1E C t� �2Y� 77S - DO(p • ° e home phone 1;/#' work phone# • CURRENT MAILING ADDRESS:__3,5 ' A l A n e L/ 113 /-2 Cif, �e✓✓, 1 ( A— og Co 3a city/town state zip code The current exemption for"homeowners"was extended to include owner-occuoied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINTITON OF HOMEOWNER Person(s) who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner'shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building,per mit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedure�s and requirements. g ( Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing.35.000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S F.MWTION The Code states that "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors.Section 2.15) This lack of awareness often results in serious problems.particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as pan of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may caret amend and adopt such a form/certification for use in your community. Q:FORMS:EXEMPTN Permit#Engineering Dept. (3rd floor) Map Parcel Z3 f House#:-. Date Issued 7_/2 -72!� Board of Health(3rd floor)(8:15 -9:30/-1:00- �- Fee Conservation Office(4th floor)(8:30- 9:30/1:00-2:00) - Planning Dept.(1st floor/School Admin. Bldg.) IMF Definitive Plan Approved by Planning Board 19 �. ' BARNSTABLE. • P MASS. - 039• TOWN OYBARNSTABLE r. Building Permit Application Project StAddress - , P Village . ✓o #e e v- Owner S o (•� �'AnHH dress _ , P Telephone Permit Request i First Floor / square feet Second Floor ' square feet Construction Type Estimated Project Cost $ S� ' Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No. of Bedrooms: Existing New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name QQ A/VN �' 4:::AGo Zt4 Telephone Number Address License# Home Improvement Contractor# /f a_5 56 Worker's Compensation# (�(.e�15 Kp NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT) SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Gc/I/ SIGNATURE DATE /� BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)• j �. S FOR OFFICIAL USE ONLY PERMIT NO. 22 DATE ISSUED # r •, Y � MAP/PARCEL NO i a L DDRESS r { '+r` VILLAGE A OWNER DATE OF.•'INSPECTION: FOUNDATION 4 ' FRAME INSULATION r_ FIREPLACE 1 , ELECTRICAL: ROUGH r f FINAL f PLUMBING: ROUGH FINAL 1 '. GAS: , t ROUGH FINAL ' FINAL BUILDING ' DATE CLOSED OUT ASSOCIATION PLAN NO. { r 1 __. - sue- the The Town of Barnstable 1e$ Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph��= BuiIding Commission: Fax: 309-790-6 o For office use only E ! t Permit no. Date °`7 e' � AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c 142A requires that the "reconstruction, alterations, renovation, repair, modernization. conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least_one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work: ' Fat.Cost IVSJ Address of Work• Owner's Name Date of Permit Application: 1 hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000. BuiIding not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS .PULLING .THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a.permit as the agent of the owner- Dati Contractor Name Registration No. OR Date Owner's Name F`t The Commonwealth of Massachusetts 4= '_ :_Z� Department of Industrikl Accidents ^ =°��� � Olfice nl/nsestigations 600 Washington Street ,+ Boston,Mass. 02111 •__r= * Workers, Compensation Insurance Affidavit name location '-7 LJ city C d / vhone# tvo -ap 9,@ ❑ I am a homeowner performing all work myself. ❑ I am a sole roprietor and have no one working in any capacity %///%% /%/%%%/%% ,'O// I am an employer providing workers' compensation for my employees working on this job. comvanv name address city hone#: insurance co. fVAolicv# (/�v = 6 //%///%/%i%/////%//%///%%//// ////////...////// fisted be ❑ I am a sole proprietor,genera contractor, or homeowner(circle one)and have hired the contractors listed below who have j the following workers' compensation polices: . com any name, address: ci hone#: insurance co nlicv# Company name: address* hone#: city. .. :.. ;; Insurance co olicv#70 Fafiure to secu coverage as requited under Section 25A of NIGL 152 can lead to the Lnposition of criminal penalties of a fine up to 51,500.00 and/or re one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a copy of this statement maybe forwarded to the omce of investigations of the DIA for coverage verification. I do hereby cent' r e d pens of perjury that the information provided above is true and correct sipattlre Print name rn.•^ C ,���"'`�'" Phone# of1►ciai use only do not write in this area to be completed by city or town oMcial city or town permtt/llcense# ❑Building Department ❑Licensing Board ❑Selectrnen's OfIIce ❑checkff immediate response is required ❑Health Department Other contact person: phone#: ❑ (mvued 9/95 PJA) c Information and Instructionsr. er 152 section 25 requires all employers to provide workers' compensation for their Massach usetts General Laws chapt ce of another under any corlffac employees. As quoted from the"law", an employee is defined as every person in the serve P of hire, express or implied, oral or written. ore of An employe r is defined as an individua, Partnership, association. corporation or other legal entity, or o o o mthe ever . the foregoing engaged in a joint enterprise, and including the legal representatives of employees. However the owner of a trustee of an individual,partnership, association or other legal enttty, employing g P house of dwelling house having not more than three apartmentsrein, or the occupant of e , nsand uction or repairho des workwok on such dwelling house othe ron th grounds o' another who employs persons to do maintenan not because of such employment be deemed to b�an err.^rloy bang appurtenant thereto shaller. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or lth for any appliantho ha in the of a license or permit to operate a business oenew n to construct ce with the insurances escoverage required. Additionally,neither the not produced acceptable evidence of comply for the perf commonwealth nor any of its political subdivisions shall requirements any chhapterr have been presented nted to the con=ccd= acceptable evidence of compliance with the insurance of public work until e q authority. �z �g/�%/ �/OOP/����0�//���%%�������0�/JINNI������//O��/�%/�/��/��/����,/>,;. Applicants Please fill in the workers' compensation affidavit completely, by checking the boxate of thatinsu applience s all your may be SUP company names, address and phone numbers along with a certificate submitted to the Department of Industrial Accidents for confirmation�o��anaPPlicati nefor the permit or lic. Also be sure to ense is d date the affidavit. The affidavit should be returned to the city arding the"law"or if you being requested, not the Department of�a��olicyl please call the Department ats. Should you have any t questions fisted below. are required to obtain a workers' comp P IBM City or Towns printed legibly. The Department has provided a space at the bottom of the ' complete and prm gl . Please be sure that the affidavit u P you regardingthe applicant. Please of Investigations has to contact y affidavit for you to fill out in the event the Officeg be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned io the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investlgallons 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-774 \ +i�f' phone#: (617) 727-4900 eat. 406; 409 or 37 5 le — _�I� �r¢�t-•k ��I .,�1�,(//�����'J/7 '�x'i ME *�x1 >•a���C"`�� L h 3 y !} y+" 49;?f T l9h'ratl g.411w 0 „ e ; 7 .�7�.5�.l�p�Y'`� 'Z I A tY.�'� Tip � + • Am • `T�,.,tg N�fAq �{ Y r q i"Y.,r��;; `Z,kK;��""Siu.,' 3 i�11]•^'�F {'�F yy..'�+ +h k .d+y'S '1 bs'T'e- Y. i< A ��`�+ r�A3`�Y�K1:.4'�'„T, rc J F ry ii •J'�r � :At >7�... naa„y s`� t -A t j A ms M1- • _ 'K!f?' �� �r�'jRFY' � 1.. 9 ;rAt'�' !r-} f'y Cp��[+��f �j�y+ 't9,4Ft J. r : hl � +!5 s-Irr_^l�� }``r�l r °I i`j 56 �,• A � s^ lr -.